Has obesity been mislabeled as a disease? Why doctors don’t mind

Weight management specialists widely cheered the American Medical Association’s decision to label obesity as a disease at its annual meeting last week—including those who have previously argued that obesity isn’t always equivalent to poor health.

“I’m okay with it,” said Timothy Church, director of preventive medicine research at Pennington Biomedical Research Center in Baton Rouge, La. “If that’s what it’s going to take to get reimbursement for treatments.”

Advertisement - Continue Reading Below

A study he published last year found that being physically fit can counteract the detrimental health effects of obesity and that obese folks who walk at a moderate pace for 30 minutes five days a week have similar cholesterol, blood pressure, and blood sugar levels as sedentary folks who are at a healthy weight.

The definition of obesity as a measure of body mass index—a calculation based on weight in relation to height—is tied to disease risks. “The higher your BMI, the higher your risk for certain diseases such as heart disease, high blood pressure, type 2 diabetes, gallstones, breathing problems, and certain cancers,” states the National Institutes of Health on its website.

How can a measure of disease risks also be a disease?

Steven Blair, a University of South Carolina obesity and fitness researcher, doesn’t think it should. “I do not agree with the AMA’s decision,” he said. “We have published numerous papers in high quality journals showing that obese individuals who have a moderate level of aerobic fitness have no increased mortality risk.” He added that inactivity and low fitness are “much bigger public health problems” than obesity. Blair, himself, is fit and obese.

But Boston-area physicians who treat obesity believe that the AMA’s new designation will improve insurance reimbursements for obesity drugs, surgery to shrink the stomach and reverse the condition, and counseling to help overweight folks make lifelong changes to their diet and activity regimens.

“I think the debate is semantic. If calling obesity a disease will coax insurance companies into providing proper coverage, then I’m all for it,” said Dr. David Ludwig, director of the Optimal Weight for Life Clinic at Boston Children’s Hospital.

Insurance companies are already being pressured to improve their coverage after a federal task force of preventive health experts last year recommended that doctors screen for obesity and provide counseling themselves or referrals for weight loss programs.

“We’ve been working towards this for the past 20 years, those of us in the trenches treating obesity,” said Dr. Caroline Apovian, director of the nutrition and weight management center at Boston Medical Center. “We’ve been trying to get coverage and recognition that obesity isn’t a matter of poor willpower but should be treated like a disease.”

Critics of that position contend that the disease designation takes responsibility off of patients to alter their diet and activity levels, but Apovian said that doesn’t hold true for other diseases like type 2 diabetes and heart disease where it’s clear that lifestyle changes can help patients better manage their condition.

When I pressed her on how most behavioral techniques fail to help obese patients lose significant amounts of weight over the long haul, she pointed out that even a 10 percent weight loss can result in a 20 percent reduction in obesity-related conditions like arthritis, type 2 diabetes, and high blood pressure. She also referred to research suggesting that sweetened, highly-processed foods can be addictive with parallels to diseases like alcoholism. “Packaged goods high in sugar and calories affect satiety pathways in the brain and make people want to eat more,” she said.

An intriguing new study published Wednesday by Ludwig and his colleagues in the American Journal of Clinical Nutrition found that when overweight people eat carbohydrates that are rapidly digested by the body—such as pretzels, white bread, or sugar-sweetened beverages—they have a quicker spike in their blood sugar and more activation in the reward centers of their brain that give them pleasure, similar to a drug addict getting a fix.

After the high wears off and blood sugar levels rapidly fall, people wind up craving more of the same foods, Ludwig said.

“It’s the difference between walking past a pastry shop because you know you don’t need the 500 calorie bear claw and ultimately giving in to the temptation,” he said.

With one-third of Americans falling into the obesity category and another one-third who are overweight, there’s legitimate concern that some may be overdiagnosed with a disease and put on expensive prescription drugs—like the recently approved Qsymia and Belviq—or given surgery they don’t need. Church acknowledged that with the new label doctors may be inclined to put too much emphasis on the scale without taking into account a patient’s physical fitness, family history, and risk factors like high cholesterol and hypertension.

But he said he changed his stance on obesity as simply a failure in lifestyle choices after studying the condition for years.

“I really developed a respect for how hard it is to lose weight and keep it off,” he said. “Until insurance companies move towards reimbursement, I don’t think we’ll make much headway” on helping people prevent or better manage obesity.